Temporal Reduction

Q: Dr. Eppley, I was curious how your temporal reduction procedure is done. Do you remove the whole portion of the muscle directly in front of and behind the ear or do you reduce the depth/thickness of the muscle? I have attached a picture that shows what I am talking about specifically. If you do remove the whole portion of the muscle, then what happens if the muscle was too thick and then there is now a visible transitions into the anterior portion of the muscle. I’m worried that it might look odd. What are your thoughts?

temporal-reduction-diagramA: Thank you for your inquiry about posterior temporal reduction. You are correct in that this is a muscular reduction procedure to decrease head width above the ears. Your attached diagram shows very precisely the location of the muscle removal. I could not have drawn it any better myself. It is not really possible to remove just a portion of the muscle and, even if you could, you would not want to. To make a visible head width narrowing it requires the entire thickness of the muscle to be reduced which is usually 5 to 7mms. (or more in some patients) Your concern about having an uneven edge to the back part of the anterior temporalis muscle (a step-off) is a valid one and a finding I have observed every time I do the procedure. But it is a self-solving problem as the muscle edge shrinks down and becomes more feather edged as it heals. (muscles shrink and contract when injured) This is also helped by using electrocautery at the muscle edge to induce it to shrink as well as the entire temporal reduction procedure is done in the subfascial plane. The tight overlying fascial layer acts to push the muscle down and obscures this temporary step-off as it heals.

Dr. Barry Eppley
Indianapolis, Indiana

Jaw Advancement

Q: Dr. Eppley, Thirty four years ago (when I was 12) I had 4 teeth extracted and braces. This pushed back my maxilla and mandible. I saw that you do jaw advancement, sometimes without orthodontics, and I really feel that I need that to open my airways. I’m so tired, yet can’t sleep properly. I was recently diagnosed with sleep apnea. How much is this type of surgery and do you accept Aetna?

A: Thank you for your inquiry. What you are referring to is Bimaxillary Advancements (upper and lower jaw advancement) for sleep apnea. You can’t just move the upper jaw forward alone as that would throw off your bite considerably. One needs to move both the upper and lower jaws forward together so the bite remains the same. This is sometimes covered by insurance but requires a very specific set of qualifications. I would go to Aetna’s policy online and look under what is required in the surgical treatment for sleep apnea. They have very strict criteria for coverage. This is the first place to start. While such surgery can be done like any other aesthetic surgery from a cost basis, it is important to initially see whether you would qualify under your health insurance.

Dr. Barry Eppley
Indianapolis, Indiana

Reverse Tummy Tuck

Q: Dr. Eppley, Was told by another ps that I’d need a reverse tummy tuck due to existing scar on my stomach. Is this so and what type of results would I get? Have you done this procedure before?

A: Thank you for your inquiry. While your large abdominal scar is certainly an issue for any form of a tummy tuck, I do not see a reverse tummy tuck of being beneficial for you. Reverse tummy tucks are usually down on patients whose lower abdomen is flat and the loose skin they have is above the belly button. Thus by pulling up on the upper abdominal skin the tissue overhang around the belly button is improved. And most of these women are usually thinner with a simple skin pull can be more effective. This is clearly not the situation you have. While you could do a reverse tummy tuck it will have virtually no effect on your lower abdomen and does not really solve the vascular risk issue that you have with your current abdominal scar. In conclusion I have done a fair number of reverse tummy tucks and you would not be a candidate for one in my opinion. The only tummy tuck that would be effective is a more traditional lower tummy tuck. Your large scar does give one pause when considering that procedure but that is a separate issue from your initial question.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I recently consulted with another surgeon about facial reshaping surgery and his recommendation was to 1) shave down/narrow the chin (as I find it to be too broad) 2) insert implants to create a more angular jawline (in addition my left side is noticeably undeveloped and 3) fat transfer to my cheeks to create more fullness. I am very much at the stage of booking the procedure but i have read a lot of reviews about Dr Eppley (most particularly in regard to these specific procedures) and I would be very keen hear his thoughts..Looking forward to hearing from you.

A: While I would largely agree with those general facial reshaping concepts I would do some of the three procedures differently. Chin narrowing can be done by either shaving or t-shaped intraoral osteotomies. Depending on the type of chin change you are seeking, the latter is usually more effective. Jaw angle augmentation depends on whether width, vertical lengthening or some amount of both are needed. That determination can not be done based on a  frontal picture alone, it takes oblique and side view images as well to see who such jaw angle changes would look. I would not use fat for your cheek augmentation. You are too thin to have that work very well. Cheek implants are more predictable and long-lasting. What style and size of cheek implant depends on the type of cheek augmentation change you seek.

Dr. Barry Eppley
Indianapolis, Indiana

Breast Implant Removal

Q: Dr. Eppley, I am considering breast implant removal. I have bilateral breast implants and now they are encapsulated the left is going under my armpit when I lay down. My insurance is paying for removal of implants and encapsulation removal. My Dr said it would cost $7000 to have new ones put it. I can’t afford that as I’m on Medicaid. I can afford the cost of implants themselves but not for the surgery room, anesthesia and the drs work even though I’ll already be having the other surgery paid for by insurance. My question is how bad will I look after this surgery. I’m so depressed and scared that I’m going to look deformed again.

A: I can not really answer your question without seeing pictures of your current breast situation. But it would be fair to say that the removal of breast implants does not usually return one to their pre surgical breast look. One’s breasts will usually appear worse than they originally were due to the stretched out skin and loss of further breast tissue. This if you felt that your breasts were deformed before the implants were put in then it is very likely that you will feel more so when these implants are removed.

Dr. Barry Eppley
Indianapolis, Indiana

Breast Fat Transfer

Q: Dr. Eppley, I am interested in breast fat transfer. I am average in weight and size (5″8 and 137lbs), but seem to develop fat around my obliques (stomach and lower back) and arms much more than the rest of my body; plus I have very small breasts and buttocks. I am very healthy and no matter how much I work out and eat a great diet, those areas of fat won’t budge. I would like to transfer fat from my stomach, lower back, and arms toward my breasts (and possibly my butt depending on the cost). How experienced is your team in breast fat transfers, because I know that it takes multiple people to keep the fat alive while transferring it?

A: While any fat harvested from liposuction can be used for transfer, it is not likely you will have much to actually put into the breasts. And most certainly there would not be enough for both breasts and buttocks. Thus you would need to concentrate any fat harvested for your breast fat transfer.

To give you some perspective on what success breast fat transfer may achieve in breast augmentation, it is important to understand the ‘halfing’ rule. The relevance of this is in getting a visual idea of how much breast size increase may realistically be obtainable. To start let’s make the basic asssumption that it takes about 150cc of fat (or an implant) to make a cup size difference. I will assume based on your description that between the stomach, arms and lower back you may have 1200ccs to harvest. (and that may be a generous estimate but I will use this number) When this amount of liposuction aspirate is then concentrated during surgery (and it is not true that it takes multiple people to keep the fat alive), it usually amounts to in women that around 40% will be end up being concentrated fat and available for injection. This leaves 480cc to be evenly divided between the breasts or 240cc injected per breasts. Then one can estimate that only 50% or half if the injected amount will survive or 120cc per breast. (the percent survival could be higher or lower…but it is almost always lower and rarely higher)

In conclusion you may be able to get a 1/2 cup size breast increase and that is if you can get 1200ccs aspirate and 50% of what is injected survives. The point being is that you might as well take whatever fat is harvested and use it for transfer into the breast but at best the breast augmentation result will be very modest in size. It is important, therefore, to have very realistic expectations. I would consider your procedure as liposuction first and anything that comes of the breast augmentation efforts as a bonus result.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal Surgery

Q: Dr. Eppley, I have some questions about rib removal surgery: 

1. Is the surgery life threatening?

2. Is the surgery considered major surgery?

3. Once the ribs are removed, what negative aspect does that subject your body to, if any?

4. What is the procedure as far as surgery, hospital stay, aftercare, and recovery time?

5. Is the surgery performed in a hospital or the doctor’s clinic?

6. What is the price of the surgery? Does that include aftercare?

7. Are there any additional costs and what would they be and if applicable what would they be

8. How many rib removal surgeries has the doctor performed?

9. Looking at the before and after photos I provided, does the doctor feel he can achieve the result provided in the after photos with the rib removal surgery?

A: In answer to your questions about rib removal surgery:

  1. The surgery is most definitely not life threatening.
  2. It depends on how you define major surgery. Compared to surgeries like breast augmentation it would be considered major. But compare to surgeries tummy tuck and BBL surgery, it would be considered less severe.
  3. I am not aware of any negative aspect of rib removals other than the fine line scars it takes to do perform the procedure.
  4. This is done in a private surgery center under general anesthesia as an overnite stay.
  5. It is done in neither a hospital or a clinic but in a surgery center.
  6. My assistant will pass along the cost of the surgery to you tomorrow. Whether you need any aftercare or not depends on whether you are traveling along or with someone.
  7. The surgical quote will be all inclusive of the surgical experience.
  8. I have removed hundreds of ribs for a variety of body contouring and recostructive surgeries.
  9. I do not think the result you are showing is realistic unless you do a lot of additional waist training after the surgery. By itself it can produce about half of your imaged result.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Knob Reduction

Q: Dr. Eppley, I had contacted you about a year ago about my occipital knob reduction surgery. I have since been saving money for this procedure with you. I have also been following procedures you have performed and posted on your website. One that I found very impressive was the occipital implant with knob reduction using a custom implant. I have taken some more profile pictures and played around with possible outcomes. I have attached those to this email. If you could please give me your suggestions and opinions on this that would be great.

A: Good to hear from you again. What you have shown would be a beautiful addition to your occipital knob reduction since you really have a combined occipital problem of a lower protrusion (occipital knob) and an upper deficiency. (occipital flatness) Normally an occipital implant is done by a custom approach using a 3D CT scan. But I have done so many of these occipital implants that in some cases, to save money and still get a good result, I will use another patient’s occipital implant design. (this is known as a semi-custom implant) That saves a fair amount of money and the shape of the flat back of the head is only minimally different amongst most patients as long as there is not a significant occipital asymmetry. The implant is also flexible so there is a lot of give for its fit onto the bone. (once on the bone it feels hard just like bone however)

Dr. Barry Eppley

Indianapolis, Indiana

Reversal Jawline Reduction Surgery

Q: Dr. Eppley, I am looking for reversal jawline reduction surgery to undo my prior V-line jaw reshaping. I have sent you a 3D CT scan. Cal you tell me what procedures I need to get back the jawline that I had?

A: I have reviewed your 3D CT scan and I can now report on what was done on your jawline reduction procedure. You had a straightforward sliding genioplasty of maybe 5mms advancement. (very small) There were three plates used for its fixation. No width reduction as done on the chin, it was simply brought forward. There are no appreciable changes to the rest of the bony jawline. The jaw angles remained structurally intact  (no amputation of the angles) There may have been some burring done for a little width reduction but not much.

In conclusion your reversal jawline reduction procedure to return you as close to where you were before would consist of the following:

1) Reversal setback genioplasty

2) Width only jaw angle implants of a small size. (3mm)

Based on the 3D CT scan I do not see the benefit of making custom implants. The chin needs to be set back and performed srandard jaw angle implants can be used too restore the jaw angle width.

Dr. Barry Eppley
Indianapolis, Indiana

Kybella

Q: Dr. Eppley, I have been researching Kybella treatment for my moderate jowl laxiity. I consulted with a plastic surgeon and he rejected me suggesting that I lose weight. I am 53 years old, 5’6″ and weigh 150 lbs. I averaged 127lbs through my 40’s to the present. I have great confidence in my dermatologist and she has recommended two treatments of Kybella,and has told me there is a 4% chance of a temporary drooping of the mouth. Most of my research says that Kybella is not recommended for the jowls. I am writing to you because you are the first I’ve come across to suggest that it can be effective for that area. Could you tell me with your experience to this date, if you still think it can be relatively safe and effective in smoothing a mild/moderate jowl sag? Many thanks in advance for your response.

A: The concept of injection lipolysis (Kybella is the one brand name for now) can be done anywhere there is fat. It is not a question of whether it can be done but whether it will be effective and has a low risk of problems in doing so. Thus the jowls can be injected and some mild improvement may be capable of being achieved. It will not be as effective as small cannula liposuction or even a small jowl tucked however. The risk of injecting the jowls is injury to the marginal mandibular branch of the facial nerve. Such injury will not cause month drooping but rather will cause lower lip elevation and smile asymmetry. Such an injury can occur from the intense inflammatory reaction that the injected deoxycholic acid solution causes. Such a reaction occurs in a 1 cm zone around each injection site. As long as one stays well away from the marionette line area of the chin this complication can be avoided. I have never seen it occur in the patients I have injected.

Dr. Barry Eppley
Indianapolis, Indiana